HomeMy WebLinkAboutSeptic Pumping Slip - 286 RALEIGH TAVERN LANE 9/12/2017Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
T. 1 2 2017
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this forrn. for use.by local Boards Of Health. Other forms may be used, but the
informationmust be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
. A. Facility, Information
1. System Location: Left / Right front of hous ighia cf7fT-,,Js6, Left/ right side of house, Left /
Right side of building, Left / Right front of buil mg, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
State Zip Code
Name
Address (if different from location)
City/Town
•
State
Telephone Number
ZipkCode
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
3. Type -of system: 0 Cesspool(s) DSTank E] Tight Tank
ID Other (describe):
4. Effluent Tee Filter present? 0 Yes E:ktCIf yes, was it cleaned? 0 Yes ti No
" 5. Condition of System:
Gallons
6: System Pumped By:
Neil Bates -on •
' Name
Bateson Enterprises Inc
Company
7. Location where contents -were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Sign e. Haule4 J Date
t5form4.doc• 08/03 System Pumping Record • Page 1 of 1